- There's a stunning new explanation for upscale longevity,
and it's quite contrary to what the world's health bureaucrats have been
telling us.
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- One of the great mysteries of modern medicine: Why do
rich people live longer than poor people? Why is it that, all around the
world, those with more income, education and high-status jobs score higher
on various measures of health? As stated in a World Health Organization
pamphlet: "People further down the social ladder usually run at least
twice the risk of serious illness and premature death of those near the
top."
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- The traditional answer to these questions has been that
greater wealth and social status mean greater access to medical care. But
even ten years ago, when this magazine last delved into the topic (FORBES,
Jan. 31, 1994), the available answers seemed inadequate. If access was
the key, then one would have expected the health gap between upper and
lower classes to shrink or disappear with the advent of programs like Britain's
National Health Service and America's Medicare and Medicaid, not to mention
employer-sponsored health insurance. In fact, the gap widened in both Britain
and America as these programs took effect. The 1994 article cited a study
of British civil servants--all with equal access to medical care and other
social services, and all working in similar physical environments--showing
that even within this homogeneous group the higher-status employees were
healthier: "Each civil service rank outlived the one immediately below."
How could this be?
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- Today the standard answer--or, at least, the answer you
are guaranteed to get from the WHO and other large health bureaucracies--is
that inequality itself is the killer. The argument is that low status translates
into insecurity, stress and anxiety, all of which increases susceptibility
to disease. This psychosocial case is lengthily elaborated in Social Determinants
of Health, a 1999 publication collectively created by 22 medical specialists
and endorsed by the WHO. "Is it plausible," the book asks at
one point, "that the organization of work, degree of social isolation
and sense of control over life could affect the likelihood of developing
and dying from chronic diseases such as diabetes and cardiovascular disease?"
The authors' answer is a resounding yes. Pushing their case to the outer
limits, the authors supply data indicating that in the world of African
wild baboons, those who are socially dominant tend to be most healthy (as
mainly evidenced in their higher levels of good cholesterol).
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- This revised standard answer has some plausibility, but
also some serious weaknesses. One of its problems is that we lack serious
comparative data on tension and anxiety levels in low- and high-status
jobs. It is far from clear that barbers, elevator operators and lower-level
civil servants suffer more tension than do surgeons, executive vice presidents
and higher-level civil servants. Another problem is that psychosocial explanations
don't tell us why the health gap would widen when employers and governments
provide more health care. Nor do they explain one well-known source of
the health gap: the notoriously high rate of smoking in the low-status
population.
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- An explanation not presenting these problems has recently
been proposed in several papers by two scholars long associated with IQ
studies: Linda Gottfredson, a sociologist based at the University of Delaware,
and psychologist Ian Deary of the University of Edinburgh. Their solution
to the age-old mystery of health and status is at once utterly original
and supremely obvious. The rich live longer, they write, mainly because
the rich are smarter. The argument rests on several different propositions,
all well documented. The crucial points are that (a) social status correlates
strongly and positively with IQ and other measures of intelligence;(b)
intelligence correlates strongly with "health literacy," the
ability to understand and follow a prescription for disease prevention
and treatment; and (c) intelligence is also correlated with forward planning--which
means avoidance of health risks (including smoking) as they are identified.
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- The first leg of that argument has been established for
many decades. In modern developed countries IQ correlates about 0.5 with
measures of income and social status--a figure telling us that IQ is not
everything but also making plain that it powerfully influences where people
end up in life. The mean IQ of Americans in the Census Bureau's "professional
and technical" category is 111. The mean for unskilled laborers is
89. An American whose IQ is in the range between 76 and 90 (i.e., well
below average) is eight times as likely to be living in poverty as someone
whose IQ is over 125.
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- Second leg: Intelligent people tend to be the most knowledgeable
about health-related issues. Health literacy matters more than it used
to. In the past big gains in health and longevity were associated with
improvements in public sanitation, immunization and other initiatives not
requiring decisions by ordinary citizens. But today the major threats to
health are chronic diseases--which, inescapably, require patients to participate
in the treatment, which means in turn that they need to understand what's
going on. Memorable sentence in the Gottfredson-Deary paper in the February
2004 issue of Current Directions in Psychological Science: "For better
or worse, people are substantially their own primary health care providers."
The authors invite you to conceptualize the role of "patient"
as having a job, and argue that, as with real jobs in the workplace, intelligent
people will learn what's needed more rapidly, will understand what's important
and what isn't and will do best at coping with unforeseen emergencies.
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- It is clear that a lot of patients out there are doing
their jobs very badly. Deary was coauthor of a 2003 study in which childhood
IQs in Scotland were related to adult health outcomes. A central finding:
Mortality rates were 17% higher for each 15-point falloff in IQ. One reason
for the failure of broad-based access to reduce the health gap is that
low-IQ patients use their access inefficiently. A Gottfredson paper in
the January 2004 issue of the Journal of Personality & Social Psychology
cites a 1993 study indicating that more than half of the 1.8 billion prescriptions
issued annually in the U.S. are taken incorrectly. The same study reported
that 10% of all hospitalizations resulted from patients' inability to manage
their drug therapy. A 1998 study reported that almost 30% of patients were
taking medications in ways that seriously threatened their health. Noncompliance
with doctors' orders is demonstrably rampant in low-income clinics, reaching
60% in one cited s tudy. Noncompliance is often taken to signify a lack
of patient motivation, but it often clearly reflects a simple failure to
understand directions.
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- A new Test of Functional Health Literacy of Adults can
evaluate the problem in a mere 22 minutes. It measures comprehension of
the labels on prescription vials, of appointment slips, of what the patient
is expected to do before diagnostic tests, etc. The results turn out to
be somewhat horrifying. In a sample of 2,659 clinic patients in two urban
hospitals, 42% did not understand the instructions for taking medicine
on an empty stomach, and 26% did not understand when the next appointment
was scheduled. The problem is maximized for patients with chronic illnesses.
Asthma, diabetes and hypertension all require patients to make a lot of
decisions daily as well as in emergencies, but many patients are simply
not up to it. A study cited in the Gottfredson-Deary paper mentions that
a high proportion of insulin-dependent diabetics did not know how to tell
when their blood sugar was too high or too low or how to get it back to
normal.
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- And then there is the third leg of the IQargument: the
lifestyle question. Smoking, obesity and sedentary living are more prevalent
among low-status citizens. A 2001 study by the Centers for Disease Control
& Prevention found that college graduates are three times as likely
to live healthily as those who never got beyond high school. Not clear
is what the government can do about this.
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- The data on IQ, social status and health present some
huge conundrums for policymakers. For years Americans debated what to do
for, and about, poor people unable to pay for health care. Ultimately they
decided it simply had to be paid for. But now, with money ordinarily not
a barrier to medical care, we are discovering another obstacle: "regimen
complexity." As this fact of life sinks in, the system will be under
pressure to find ways to deliver high-quality care to the low-status population
much more simply, understandably--and economically. Not an easy task.
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